Bill S7882-2013

Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits

Relates to insurance coverage for diagnosis and treatment of substance use disorder benefits; creates a workgroup to study and make recommendations on improving access to and the availability of chemical dependency or substance use disorder treatment services.

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  • Jun 16, 2014: REFERRED TO RULES

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BILL NUMBER:S7882

TITLE OF BILL: An act to amend the insurance law and the public health law, in relation to requiring health insurance coverage for diagnosis and treatment of substance use disorder treatment services and creating a workgroup to study and make recommendations

PURPOSE: This legislation clarifies that health insurance coverage must provide for substance abuse disorder treatment services improves the utilization review process for determining such insurance coverage and requires insurers to continue to provide coverage throughout the entire appeals process.

SUMMARY OF PROVISIONS: Sections one, two and three amend sections 3216, 3221 and 4303 of the insurance law to clarify that health plans shall include specific coverage for drug and alcohol abuse and dependency treatment services pursuant to the federal Mental Health and Parity Act of 2008 and applicable state statutes. It also requires a health plan to use a health care provider who specializes in substance abuse disorder treatment when conducting medical management or utilization review and requires the use of evidence-based and peer-reviewed clinical review criteria as deemed appropriate and approved by OASAS in consultation with DFS and DOH. This section also requires all internal and external appeals to be conducted on an expedited basis and health plans to provide coverage for substance abuse services until all appeals, both internal and external, have been exhausted.

Sections four through nine make similar corresponding changes in sections 4902, 4903, and 4904 of the insurance law, and sections 4902, 4903 and 4904 of the public health law.

Section ten requires DFS to select a random sampling of substance abuse coverage determinations and provide an analysis of whether or not such determinations are in compliance with the criteria established in this act and to submit a report by December 31, 2015.

Section eleven creates a workgroup to study and make recommendations on improving access to and availability of substance abuse and dependency treatment services. The workgroup shall submit a report by December 31, 2015.

Section twelve provides for a January 1, 2015.

JUSTIFICATION: The New York State Senate Heroin and Opioid Task Force has held hearings throughout the state to discuss the rise in the use of heroin and other opioids in New York State and to develop recommendations for treating and preventing addiction. At each of these hearings, the issue of health insurance coverage has been at the forefront. This legislation will improve access to care by ensuring that decisions regarding treatment are standardized and that they are made by medical doctors who specialize in behavioral health and substance abuse. Further, the legislation also ensures that individuals requiring treatment have access to an expedited appeals process and that they are not denied care while the appeals process is underway. The legislation also establishes a workgroup to be convened jointly with OASAS, DFS and DOH in order to study and develop

recommendations on improving access to and availability of substance abuse and dependency treatment services.

LEGISLATIVE HISTORY: New bill.

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: Jan 1, 2015


Text

STATE OF NEW YORK ________________________________________________________________________ 7882 IN SENATE June 16, 2014 ___________
Introduced by Sens. SEWARD, HANNON -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law and the public health law, in relation to requiring health insurance coverage for diagnosis and treatment of substance use disorder treatment services and creating a workgroup to study and make recommendations THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subsection (i) of section 3216 of the insurance law is amended by adding a new paragraph 30 to read as follows: (30) (A) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR-MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE COVERAGE FOR DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA- TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI- TATION SERVICES. (B) IN THE EVENT OF AN ADVERSE DETERMINATION FOR SUBSTANCE USE DISOR- DER TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVER- AGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS FOR SUBSTANCE USE DISOR- DER TREATMENT SERVICES RENDERED WHILE THE PROVIDER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILIZATION REVIEW AGENT.
S 2. Subsection (l) of section 3221 of the insurance law is amended by adding a new paragraph 19 to read as follows: (19) (A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIV- ERY IN THIS STATE WHICH PROVIDES MAJOR MEDICAL OR SIMILAR COMPREHEN- SIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA- TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI- TATION SERVICES. (B) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF-POCKET COSTS FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID- ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI- ZATION REVIEW AGENT. S 3. Section 4303 of the insurance law is amended by adding a new subsection (oo) to read as follows: (OO) (1) A MEDICAL EXPENSE INDEMNITY CORPORATION, A HOSPITAL SERVICE CORPORATION OR A HEALTH SERVICE CORPORATION WHICH PROVIDES MAJOR MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL INCLUDE SPECIFIC COVERAGE FOR DIAGNOSIS AND TREATMENT OF SUBSTANCE USE DISORDER BENEFITS PURSUANT TO THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008, AS AMENDED, OR OTHER APPLICABLE FEDERAL AND STATE STATUTES AND RULES AND REGULATIONS PROMULGATED THERETO WHICH REQUIRE PARITY BETWEEN MENTAL HEALTH OR SUBSTANCE USE DISORDER BENEFITS AND MEDICAL/SURGICAL BENEFITS WITH RESPECT TO FINANCIAL REQUIREMENTS AND TREATMENT OR WHICH REQUIRE COVERAGE OF SUCH TREATMENT, WHICHEVER PROVIDES A BENEFIT THAT IS MORE ADVANTAGEOUS TO THE POLICYHOLDER AS DETERMINED BY THE SUPERINTENDENT. SUCH COVERAGE SHALL INCLUDE BOTH INPA- TIENT AND OUTPATIENT TREATMENT, INCLUDING DETOXIFICATION AND REHABILI- TATION SERVICES. (2) IN THE EVENT OF AN ADVERSE DETERMINATION FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES, THE HEALTH PLAN SHALL CONTINUE TO PROVIDE COVERAGE AND REIMBURSE FOR ALL SUCH SERVICES UNTIL THE INSURED HAS EXHAUSTED ALL APPEALS, BOTH INTERNAL AND EXTERNAL, OR OTHERWISE NOTIFIES THE HEALTH PLAN IN WRITING THAT HE OR SHE HAS DECIDED TO NOT MOVE FORWARD WITH THE APPEALS PROCESS. THE HEALTH PLAN SHALL ENSURE THAT AN INSURED SHALL NOT INCUR ANY GREATER OUT-OF POCKET COSTS FOR SUBSTANCE USE DISORDER TREATMENT SERVICES RENDERED WHILE THE PROVID- ER IS APPEALING AN ADVERSE DETERMINATION FOR SUCH SERVICES THAN THE INSURED WOULD HAVE INCURRED IF SUCH SERVICES WERE APPROVED BY THE UTILI- ZATION REVIEW AGENT. S 4. Section 4902 of the insurance law is amended by adding two new subsections (c) and (d) to read as follows:
(C) I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMIN- ING HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISOR- DERS, A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO SPECIALIZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH TREATMENT. II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPER- INTENDENT. III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL- TATION WITH THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT SHALL APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA, IN ADDITION TO ANY OTHER APPROVED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA. (D) WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE APPEAL OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS SHALL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. WHERE AN INSURED'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE INSURED, EXTERNAL APPEALS OF UTILIZATION REVIEW DETERMINATION WILL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN PARAGRAPH THREE OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE. S 5. Subsection (c) of section 4903 of the insurance law, as amended by chapter 237 of the laws of 2009, is amended to read as follows: (c) A utilization review agent shall make a determination involving continued or extended health care services, additional services for an insured undergoing a course of continued treatment prescribed by a health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER, or home health care services following an inpa- tient hospital admission, and shall provide notice of such determination to the insured or the insured's designee, which may be satisfied by notice to the insured's health care provider, by telephone and in writ- ing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date. Provided that a request for home health care services and all necessary information is submitted to the utilization review agent prior to discharge from an inpatient hospital admission pursuant to this subsection, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authorization, coverage for home health care services while a determination by the utilization review agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBSECTION, A
UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECES- SITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WHILE A DETERMINATION BY THE UTILIZA- TION REVIEW AGENT IS PENDING. PROVIDED THAT UPON ADMISSION TO INPATIENT AND RESIDENTIAL TREATMENT FOR CHEMICAL DEPENDENCY OR SUBSTANCE USE DISORDER, THE UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, WHEN NOTICE OF ADMIS- SION FOR PURPOSES OF CARE COORDINATION WAS PROVIDED TO THE UTILIZATION REVIEW AGENT WITHIN TWENTY-FOUR HOURS OF AN ADMISSION; AND A REQUEST FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBSECTION. S 6. Subsection (b) of section 4904 of the insurance law, as amended by chapter 237 of the laws of 2009, is amended to read as follows: (b) A utilization review agent shall establish an expedited appeal process for appeal of an adverse determination involving (1) continued or extended health care services, procedures or treatments or additional services for an insured undergoing a course of continued treatment prescribed by a health care provider or home health care services following discharge from an inpatient hospital admission pursuant to subsection (c) of section four thousand nine hundred three of this arti- cle or (2) an adverse determination in which the health care provider believes an immediate appeal is warranted except any retrospective determination. Such process shall include mechanisms which facilitate resolution of the appeal including but not limited to the sharing of information from the insured's health care provider and the utilization review agent by telephonic means or by facsimile. The utilization review agent shall provide reasonable access to its clinical peer reviewer within one business day of receiving notice of the taking of an expe- dited appeal. Expedited appeals shall be determined within two business days of receipt of necessary information to conduct such appeal. Expe- dited appeals which do not result in a resolution satisfactory to the appealing party may be further appealed through the standard appeal process, or through the external appeal process pursuant to section four thousand nine hundred fourteen of this article as applicable. PROVIDED THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME- DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI- NATION BY THE EXTERNAL REVIEW AGENT IS PENDING. S 7. Section 4902 of the public health law is amended by adding two new subdivisions 3 and 4 to read as follows: 3. I. WHEN CONDUCTING A UTILIZATION REVIEW FOR PURPOSES OF DETERMINING HEALTH CARE COVERAGE FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDERS, A UTILIZATION REVIEW AGENT SHALL BE A HEALTH CARE PROVIDER WHO SPECIAL- IZES IN BEHAVIORAL HEALTH AND WHO HAS EXPERIENCE IN THE DELIVERY OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER COURSES OF TREATMENT TO SUPERVISE AND OVERSEE THE MEDICAL MANAGEMENT DECISIONS RELATING TO SUCH TREATMENT. II. A UTILIZATION REVIEW AGENT SHALL UTILIZE RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA THAT IS APPROPRIATE TO THE AGE OF THE PATIENT AND IS DEEMED APPROPRIATE AND APPROVED FOR SUCH USE
BY THE COMMISSIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSULTATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES. III. THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES IN CONSUL- TATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES SHALL APPROVE A RECOGNIZED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA, IN ADDITION TO ANY OTHER APPROVED EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA. 4. WHERE AN INSURED'S HEALTHCARE PROVIDER BELIEVES AN IMMEDIATE APPEAL OF AN ADVERSE DETERMINATION FOR TREATMENT RELATING TO CHEMICAL DEPEND- ENCE OR SUBSTANCE USE DISORDER IS WARRANTED, ALL INTERNAL APPEALS SHALL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS TITLE. WHERE AN ENROLLEE'S HEALTH CARE PROVIDER DETERMINES THAT A DELAY IN PROVIDING CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER TREATMENT WOULD POSE A SERIOUS THREAT TO THE HEALTH OR SAFETY OF THE ENROLLEE, EXTERNAL APPEALS OF UTILIZATION REVIEW DETERMINATIONS WILL BE CONDUCTED ON AN EXPEDITED BASIS AS SET FORTH IN PARAGRAPH (C) OF SUBDIVISION TWO OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE. S 8. Subdivision 3 of section 4903 of the public health law, as amended by chapter 237 of the laws of 2009, is amended to read as follows: 3. A utilization review agent shall make a determination involving continued or extended health care services, additional services for an enrollee undergoing a course of continued treatment prescribed by a health care provider, REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER, or home health care services following an inpa- tient hospital admission, and shall provide notice of such determination to the enrollee or the enrollee's designee, which may be satisfied by notice to the enrollee's health care provider, by telephone and in writ- ing within one business day of receipt of the necessary information except, with respect to home health care services following an inpatient hospital admission, OR REQUESTS FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER, within seventy-two hours of receipt of the necessary information when the day subsequent to the request falls on a weekend or holiday. Notification of continued or extended services shall include the number of extended services approved, the new total of approved services, the date of onset of services and the next review date. Provided that a request for home health care services and all necessary information is submitted to the utilization review agent prior to discharge from an inpatient hospital admission pursuant to this subdivision, a utilization review agent shall not deny, on the basis of medical necessity or lack of prior authorization, coverage for home health care services while a determination by the utilization review agent is pending. PROVIDED THAT A REQUEST FOR TREATMENT FOR CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBDIVISION, A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR CHEMICAL DEPEND- ENCE OR SUBSTANCE USE DISORDER TREATMENT SERVICES WHILE A DETERMINATION BY THE UTILIZATION REVIEW AGENT IS PENDING. PROVIDED THAT, UPON ADMIS- SION TO INPATIENT AND RESIDENTIAL TREATMENT, THE UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, WHEN NOTICE OF ADMISSION FOR PURPOSES OF CARE COORDI- NATION WAS PROVIDED TO THE UTILIZATION REVIEW AGENT WITHIN TWENTY-FOUR HOURS OF AN ADMISSION; AND A REQUEST FOR TREATMENT FOR SUBSTANCE USE
DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED TO THE UTILIZATION REVIEW AGENT PURSUANT TO THIS SUBDIVISION. S 9. Subdivision 2 of section 4904 of the public health law, as amended by chapter 237 of the laws of 2009, is amended to read as follows: 2. A utilization review agent shall establish an expedited appeal process for appeal of an adverse determination involving: (a) continued or extended health care services, procedures or treat- ments or additional services for an enrollee undergoing a course of continued treatment prescribed by a health care provider home health care services following discharge from an inpatient hospital admission pursuant to subdivision three of section forty-nine hundred three of this article; or (b) an adverse determination in which the health care provider believes an immediate appeal is warranted except any retrospective determination. Such process shall include mechanisms which facilitate resolution of the appeal including but not limited to the sharing of information from the enrollee's health care provider and the utilization review agent by telephonic means or by facsimile. The utilization review agent shall provide reasonable access to its clinical peer reviewer within one business day of receiving notice of the taking of an expe- dited appeal. Expedited appeals shall be determined within two business days of receipt of necessary information to conduct such appeal. Expe- dited appeals which do not result in a resolution satisfactory to the appealing party may be further appealed through the standard appeal process, or through the external appeal process pursuant to section forty-nine hundred fourteen of this article as applicable. PROVIDED THAT THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER NOTIFIES THE UTILIZATION REVIEW AGENT OF ITS INTENT TO FILE AN EXTERNAL APPEAL IMME- DIATELY UPON RECEIPT OF AN APPEAL DETERMINATION AND A REQUEST FOR AN EXPEDITED EXTERNAL APPEAL FOR TREATMENT OF CHEMICAL DEPENDENCE OR SUBSTANCE USE DISORDER AND ALL NECESSARY INFORMATION IS SUBMITTED WITHIN TWENTY-FOUR HOURS OF RECEIPT OF AN APPEAL DETERMINATION, A UTILIZATION REVIEW AGENT SHALL NOT DENY, ON THE BASIS OF MEDICAL NECESSITY OR LACK OF PRIOR AUTHORIZATION, COVERAGE FOR SUCH TREATMENT WHILE A DETERMI- NATION BY THE EXTERNAL REVIEW AGENT IS PENDING. S 10. The superintendent of the department of financial services shall select a random sampling of chemical dependence or substance use disor- der treatment coverage determinations and provide an analysis of whether or not such determinations are in compliance with the criteria estab- lished in this act and report its finding to the governor, the temporary president of the senate, and speaker of the assembly, the chairs of the senate and assembly insurance committees, and the chairs of the senate and assembly health committees no later than December 31, 2015. S 11. 1. Within thirty days of the effective date of this act, the commissioner of the office of alcoholism and substance abuse services, superintendent of the department of financial services, and the commis- sioner of health, shall jointly convene a workgroup to study and make recommendations on improving access to and availability of chemical dependence or substance use disorder treatment services in the state. The workgroup shall be co-chaired by such commissioners and superinten- dent, and shall also include, but not be limited to, representatives of health care providers, insurers, additional professionals, individuals and families who have been affected by addiction. The workgroup shall include, but not be limited to, a review of the following:
a. Identifying barriers to obtaining necessary chemical dependence or substance use disorder treatment services for across the state; b. Recommendations for increasing access to and availability of chemi- cal dependence or substance use disorder treatment services in the state, including underserved areas of the state; c. Identifying best clinical practices for chemical dependence or substance use disorder treatment services; d. A review of current insurance coverage requirements and recommenda- tions for improving insurance coverage for chemical dependence or substance use disorder and dependency treatment; e. Recommendations for improving state agency communication and collaboration relating to chemical dependence or substance use disorder treatment services in the state; f. Resources for affected individuals and families who are having difficulties obtaining necessary chemical dependence or substance use disorder treatment services; and g. Methods for developing quality standards to measure the performance of chemical dependence or substance use disorder treatment facilities in the state. 2. The workgroup shall submit a report of its findings and recommenda- tions to the governor, the temporary president of the senate, the speak- er of the assembly, the chairs of the senate and assembly insurance committees, and the chairs of the senate and assembly health committees no later than December 31, 2015. S 12. This act shall take effect January 1, 2015; provided, however, that sections one through nine of this act shall apply to all policies and contracts issued, delivered, renewed, modified, altered, or amended after such date.

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